Provider Demographics
NPI:1144389347
Name:JACKSON, ROBERT W (DDS)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:W
Last Name:JACKSON
Suffix:
Gender:M
Credentials:DDS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1696
Mailing Address - Street 2:
Mailing Address - City:THOMASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:31799-1696
Mailing Address - Country:US
Mailing Address - Phone:229-226-1919
Mailing Address - Fax:229-226-7709
Practice Address - Street 1:209 MIMOSA DR
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6633
Practice Address - Country:US
Practice Address - Phone:229-226-1919
Practice Address - Fax:229-226-7709
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GADN0075861223S0112X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1223S0112XDental ProvidersDentistOral and Maxillofacial Surgery